ISiK Basis Implementierungsleitfaden
Version 6.0.0-rc - ballot

Resource Profile: ISiKVersicherungsverhaeltnisSonstige

Official URL: https://gematik.de/fhir/isik/StructureDefinition/ISiKVersicherungsverhaeltnisSonstige Version: 6.0.0-rc
Active as of 2026-04-02 Computable Name: ISiKVersicherungsverhaeltnisSonstige

Dieses Profil ermöglicht die Darstellung sonstiger Versicherungsverhältnisses in ISiK Szenarien.

Motivation

ISiK unterstützt Anwendungsszenarien, in denen durch das Krankenhaus erbrachte Leistungen erfasst oder gegenüber Kostenträgern abgerechnet werden, bei denen es sich weder um gesetzliche Versicherungen noch Selbstzahlerverhältnisse handelt. In diesen Anwendungsszenarien wird das Versicherungsverhältnis verwendet, um bspw. den Versicherungsstatus oder die Rechnungsanschrift der Versicherung zu ermitteln.
In FHIR werden Versicherungsverhältnisse mit der Coverage-Ressource repräsentiert.

Kompatibilität

Das Profil ISiKVersicherungsverhaeltnisSonstige basiert auf dem Basis-Coverage-Profil der deutschen Basisprofile.

Hinweise zu Inkompatibilitäten können über die Portalseite gemeldet werden.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage 0..* CoverageDeBasis(1.6.0-ballot) Versicherungsdaten
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
Slice: Unordered, Open by value:url
... status ?!Σ 1..1 code Status
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... beneficiary ΣC 1..1 Reference(Patient) Begünstigte Person
Constraints: ref-1
.... reference ΣC 0..1 string Patienten-Link
... payor ΣC 1..* Reference(Patient | RelatedPerson | Organization) Kostenträger
Constraints: ref-1
.... display Σ 0..1 string Kostenträger-Bezeichnung

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Coverage.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Coverage.type Base required VersicherungsartDeBasisVS 📦1.6.0-ballot de.basisprofil.r4 v1.6

Constraints

Id Grade Path(s) Description Expression
dom-2 error Coverage If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Coverage If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Coverage If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Coverage If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Coverage A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
ref-1 error Coverage.beneficiary, Coverage.payor SHALL have a contained resource if a local reference is provided reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

This structure is derived from CoverageDeBasis

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage 0..* CoverageDeBasis(1.6.0-ballot) Versicherungsdaten
... status 1..1 code Status
... type 1..1 CodeableConcept Versicherungsart
... beneficiary 1..1 Reference(Patient) Begünstigte Person
.... reference 0..1 string Patienten-Link
.... display 0..1 string Kostenträger-Bezeichnung

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage 0..* CoverageDeBasis(1.6.0-ballot) Versicherungsdaten
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
Slice: Unordered, Open by value:url
... identifier Σ 0..* Identifier Business Identifier for the coverage
... status ?!Σ 1..1 code Status
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... type Σ 1..1 CodeableConcept Versicherungsart
Binding: VersicherungsartDeBasisVS (required): Art der Versicherung: Selbstzahler, gesetzliche/private Versicherung, Berufsgenossenschaft oder Sozialamt
... subscriber ΣC 0..1 Reference(Patient | RelatedPerson) Hauptversicherte Person / Mitglied
Constraints: ref-1
... beneficiary ΣC 1..1 Reference(Patient) Begünstigte Person
Constraints: ref-1
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Patienten-Link
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... dependent Σ 0..1 string Dependent number
... relationship 0..1 CodeableConcept Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
... period ΣC 0..1 Period Coverage start and end dates
Constraints: per-1
... payor ΣC 1..* Reference(Patient | RelatedPerson | Organization) Kostenträger
Constraints: ref-1
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Kostenträger-Bezeichnung
... class 0..* BackboneElement Additional coverage classifications
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
.... value Σ 1..1 string Value associated with the type
.... name Σ 0..1 string Human readable description of the type and value
... costToBeneficiary 0..* BackboneElement Patient payments for services/products
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type Σ 0..1 CodeableConcept Cost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.
.... value[x] Σ 1..1 The amount or percentage due from the beneficiary
..... valueQuantity Quantity(SimpleQuantity)
..... valueMoney Money
.... exception 0..* BackboneElement Exceptions for patient payments
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Exception category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.
..... period ΣC 0..1 Period The effective period of the exception
Constraints: per-1
... subrogation 0..1 boolean Reimbursement to insurer
... contract C 0..* Reference(Contract) Contract details
Constraints: ref-1

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Coverage.language Base preferred Common Languages 📦4.0.1 FHIR Std.
Coverage.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Coverage.type Base required VersicherungsartDeBasisVS 📦1.6.0-ballot de.basisprofil.r4 v1.6
Coverage.beneficiary.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Coverage.relationship Base extensible SubscriberPolicyholder Relationship Codes 📦4.0.1 FHIR Std.
Coverage.payor.type Base extensible ResourceType 📍4.0.1 FHIR Std.
Coverage.class.type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
Coverage.costToBeneficiary.​type Base extensible Coverage Copay Type Codes 📦4.0.1 FHIR Std.
Coverage.costToBeneficiary.​exception.type Base example Example Coverage Financial Exception Codes 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Coverage If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Coverage If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Coverage If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Coverage If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Coverage A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
per-1 error Coverage.period, Coverage.costToBeneficiary.exception.period If present, start SHALL have a lower value than end start.hasValue().not() or end.hasValue().not() or (start <= end)
ref-1 error Coverage.subscriber, Coverage.beneficiary, Coverage.payor, Coverage.contract SHALL have a contained resource if a local reference is provided reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

This structure is derived from CoverageDeBasis

Summary

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage 0..* CoverageDeBasis(1.6.0-ballot) Versicherungsdaten
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
Slice: Unordered, Open by value:url
... status ?!Σ 1..1 code Status
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... beneficiary ΣC 1..1 Reference(Patient) Begünstigte Person
Constraints: ref-1
.... reference ΣC 0..1 string Patienten-Link
... payor ΣC 1..* Reference(Patient | RelatedPerson | Organization) Kostenträger
Constraints: ref-1
.... display Σ 0..1 string Kostenträger-Bezeichnung

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Coverage.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Coverage.type Base required VersicherungsartDeBasisVS 📦1.6.0-ballot de.basisprofil.r4 v1.6

Constraints

Id Grade Path(s) Description Expression
dom-2 error Coverage If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Coverage If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Coverage If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Coverage If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Coverage A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
ref-1 error Coverage.beneficiary, Coverage.payor SHALL have a contained resource if a local reference is provided reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

Differential View

This structure is derived from CoverageDeBasis

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage 0..* CoverageDeBasis(1.6.0-ballot) Versicherungsdaten
... status 1..1 code Status
... type 1..1 CodeableConcept Versicherungsart
... beneficiary 1..1 Reference(Patient) Begünstigte Person
.... reference 0..1 string Patienten-Link
.... display 0..1 string Kostenträger-Bezeichnung

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Coverage 0..* CoverageDeBasis(1.6.0-ballot) Versicherungsdaten
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
Slice: Unordered, Open by value:url
... identifier Σ 0..* Identifier Business Identifier for the coverage
... status ?!Σ 1..1 code Status
Binding: FinancialResourceStatusCodes (required): A code specifying the state of the resource instance.
... type Σ 1..1 CodeableConcept Versicherungsart
Binding: VersicherungsartDeBasisVS (required): Art der Versicherung: Selbstzahler, gesetzliche/private Versicherung, Berufsgenossenschaft oder Sozialamt
... subscriber ΣC 0..1 Reference(Patient | RelatedPerson) Hauptversicherte Person / Mitglied
Constraints: ref-1
... beneficiary ΣC 1..1 Reference(Patient) Begünstigte Person
Constraints: ref-1
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Patienten-Link
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... dependent Σ 0..1 string Dependent number
... relationship 0..1 CodeableConcept Beneficiary relationship to the subscriber
Binding: SubscriberRelationshipCodes (extensible): The relationship between the Subscriber and the Beneficiary (insured/covered party/patient).
... period ΣC 0..1 Period Coverage start and end dates
Constraints: per-1
... payor ΣC 1..* Reference(Patient | RelatedPerson | Organization) Kostenträger
Constraints: ref-1
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Kostenträger-Bezeichnung
... class 0..* BackboneElement Additional coverage classifications
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type Σ 1..1 CodeableConcept Type of class such as 'group' or 'plan'
Binding: CoverageClassCodes (extensible): The policy classifications, eg. Group, Plan, Class, etc.
.... value Σ 1..1 string Value associated with the type
.... name Σ 0..1 string Human readable description of the type and value
... costToBeneficiary 0..* BackboneElement Patient payments for services/products
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... type Σ 0..1 CodeableConcept Cost category
Binding: CoverageCopayTypeCodes (extensible): The types of services to which patient copayments are specified.
.... value[x] Σ 1..1 The amount or percentage due from the beneficiary
..... valueQuantity Quantity(SimpleQuantity)
..... valueMoney Money
.... exception 0..* BackboneElement Exceptions for patient payments
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... type Σ 1..1 CodeableConcept Exception category
Binding: ExampleCoverageFinancialExceptionCodes (example): The types of exceptions from the part or full value of financial obligations such as copays.
..... period ΣC 0..1 Period The effective period of the exception
Constraints: per-1
... subrogation 0..1 boolean Reimbursement to insurer
... contract C 0..* Reference(Contract) Contract details
Constraints: ref-1

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Coverage.language Base preferred Common Languages 📦4.0.1 FHIR Std.
Coverage.status Base required Financial Resource Status Codes 📍4.0.1 FHIR Std.
Coverage.type Base required VersicherungsartDeBasisVS 📦1.6.0-ballot de.basisprofil.r4 v1.6
Coverage.beneficiary.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Coverage.relationship Base extensible SubscriberPolicyholder Relationship Codes 📦4.0.1 FHIR Std.
Coverage.payor.type Base extensible ResourceType 📍4.0.1 FHIR Std.
Coverage.class.type Base extensible Coverage Class Codes 📦4.0.1 FHIR Std.
Coverage.costToBeneficiary.​type Base extensible Coverage Copay Type Codes 📦4.0.1 FHIR Std.
Coverage.costToBeneficiary.​exception.type Base example Example Coverage Financial Exception Codes 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
dom-2 error Coverage If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Coverage If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error Coverage If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error Coverage If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Coverage A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
per-1 error Coverage.period, Coverage.costToBeneficiary.exception.period If present, start SHALL have a lower value than end start.hasValue().not() or end.hasValue().not() or (start <= end)
ref-1 error Coverage.subscriber, Coverage.beneficiary, Coverage.payor, Coverage.contract SHALL have a contained resource if a local reference is provided reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

This structure is derived from CoverageDeBasis

Summary

 

Other representations of profile: CSV, Excel, Schematron